Background: The implementation of the national health insurance program to fulfill the payment system related to a claim needs the documentation of services in the discharge summary. The objective of this study was to determine the influence of completeness supporting examination and discharge summary procedure to suitability of severity level determination in tertiary referral hospitals. 
Methods: This was an analytical study with cross-sectional design. The data were collected from observation toward inpatient’s discharge summary. Ninety-nine samples were taken by simple random sampling technique. 
Results: The results of the statistical significance test showed that the congeniality between the supporting examination results and procedure (p<0.0001) and the completeness of secondary diagnosis in discharge summary (p<0.0001) had an influence on the suitability of severity levels. 
Conclusion: Completeness supporting examination and discharge summary procedure can influence severity level.

• Amin, M., & Nasharuddin, S. Z. (2013). Hospital service quality and its effects on patient satisfaction and behavioural intention. Clinical Governance: An International Journal.
• Bauer, K., Schwarzkopf, L., Graessel, E., & Holle, R. (2014). A claims data-based comparison of comorbidity in individuals with and without dementia. BMC geriatrics, 14(1), 10.
• Departemen K. R.I. (2006). “Pedoman Penyelenggaraan Dan Prosedur Rekam Medis Rumah Sakit Di Indonesia Revisi II Tahun 2006.” Depkes RI 13–15.
• Departemen Kesehatan Republik Indonesia. (2014). “Peraturan Menteri Kesehatan Republik Indonesia Nomor 27 Tahun 2014 Tentang Petunjuk Teknis Sistem Indonesian Case Base Groups (INA-CBGs).” 50.
• Dewi, C.K. (2017). “Information Quality Assessment of Outpatient Medical Reord Document.” Indonesian Journal of Health Administration 5(1).
• Gosanti, A. Z., & Ernawaty, E. (2017). Analisis Kelengkapan Penulisan Soap, Kie, dan Icd X pada Rekam Medis di Poli Umum dan Kia-Kb Puskesmas X Surabaya. Jurnal Administrasi Kesehatan Indonesia, 5(2), 139-144.
• Hussein, R. A., Majeed, A. A., Mahmoud, R. A., Saihoud, S. A., & Al-Hamadi, N. Q. (2018). Assessment of the documentation completeness level of the medical records in Basrah General Hospital. The Medical Journal of Basrah University, 36(2), 50-59.
• Indonesia, R. (2008). Peraturan Menteri Kesehatan Republik Indonesia Nomor 269/Menkes/Per/III/2008 tentang Rekam Medis. Jakarta: Kementerian Kesehatan Republik Indonesia.
• Kind, A. J., & Smith, M. A. (2008). Documentation of mandated discharge summary components in transitions from acute to subacute care. In Advances in patient safety: New directions and alternative approaches (vol. 2: Culture and redesign). Agency for Healthcare Research and Quality (US).
• Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. Jama, 297(8), 831-841.
• Lærum, H., Ellingsen, G., & Faxvaag, A. (2001). Doctors’ use of electronic medical records systems in hospitals: cross sectional survey. Bmj, 323(7325), 1344-1348.
• Ludwick, D. A., & Doucette, J. (2009). Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries. International journal of medical informatics, 78(1), 22-31.
• Mehta, R. L., Baxendale, B., Roth, K., Caswell, V., Le Jeune, I., Hawkins, J., ... & Avery, A. J. (2017). Assessing the impact of the introduction of an electronic hospital discharge system on the completeness and timeliness of discharge communication: a before and after study. BMC Health Services Research, 17(1), 1-10.
• O’Malley, Kimberly J., Karon F. Cook, Matt D. Price, Kimberly Raiford Wildes, John F. Hurdle, and Carol M. Ashton.( 2005). “Measuring Diagnoses: ICD Code Accuracy.” Health Services Research 40(5 II):1620–39.
• Peabody, J. W., Luck, J., Jain, S., Bertenthal, D., & Glassman, P. (2004). Assessing the accuracy of administrative data in health information systems. Medical care, 1066-1072.
• Russell, P., Hewage, U., & Thompson, C. (2014). Method for improving the quality of discharge summaries written by a general medical team. Internal Medicine Journal, 44(3), 298-301.
• Samad, R., Akbar, F. H., Pasiga, B. D., Pratiwi, R., Anwar, A. I., Djamaluddin, N., & Afiyah, N. (2018). Evaluation of patient satisfaction on quality of public dental health service from different dimensions in Indonesia. Pesquisa Brasileira em Odontopediatria e Clinica Integrada, 18(1), 4033.
• Sammer, C. E., Lykens, K., Singh, K. P., Mains, D. A., & Lackan, N. A. (2010). What is patient safety culture? A review of the literature. Journal of Nursing Scholarship, 42(2), 156-165.
• Simamora, R. H.(2019). “Documentation of Patient Identification into the Electronic System to Improve the Quality of Nursing Services.” International Journal of Scientific and Technology Research 8(9):1884–86.
• Siregar, I. (2019). “Application Quality Function Deployment to Improve Quality of Patient Service in Hemodialysis Installation.” IOP Conference Series: Materials Science and Engineering 598(1).
• Thygesen, Sandra K., Christian F. Christiansen, Timothy L. Lash, Steffen Christensen, & Henrik T. Sørensen. (2011). “Predictive Value of Coding of Diagnoses in the Charlson Comorbidity Index in the Danish National Registry of Patients.” BMC Med Res Methodol. 11(83):2–7.
• Tuami, Hadijah, A. Indahwaty Sidin, & Andi Zulkifli. (2018). “The Analysis Service Quality Based on Patient Expectation and Assessment at Mamuju Regecy Local Public Hospital 2016.” ACM International Conference Proceeding Series 226–31.
• Van Walraven, C., Seth, R., Austin, P. C., & Laupacis, A. (2002). Effect of discharge summary availability during post-discharge visits on hospital readmission. Journal of general internal medicine, 17(3), 186-192.
• Zegers, M., de Bruijne, M. C., Spreeuwenberg, P., Wagner, C., Groenewegen, P. P., & van der Wal, G. (2011). Quality of patient record keeping: an indicator of the quality of care?. BMJ quality & safety, 20(4), 314-318.

This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.